New BTS/SIGN asthma guideline: interview with Dr John White

Key changes and how to interpret them

Dr John White is a member of the British Thoracic Society and Consultant Respiratory Physician, York NHS Foundation Trust, who co-chaired the group that delivered the updated BTS/SIGN Guideline

Here he discusses some of the significant changes within the guideline and what immediate actions clinicians should be employing

Hi John, welcome to Respiratory Futures.

The release of the new asthma guidelines is clearly an important milestone, demonstrating the strength of goodwill across our sector for making change. How do you see clinicians interpreting the new guidelines practically at the coalface?

I’d say it’s about taking note of the significant changes in the new version. The guideline has been updated annually, more latterly biannually, but certain key concepts have remained the same.

The diagnosis chapter hadn't changed in at least four years and is now significantly different with the new iteration. It's written with a very clinical, predominantly primary care, focus to make it useable by the vast majority of clinicians who are seeing people and trying to diagnose, and also exclude, a diagnosis of asthma.

There are also major changes in the pharmacology section which I think most people regard as the lynchpin of the whole guideline. It is probably the most read, cited and referred-to element in day-to-day practice.

A key change our pharmacological therapy section is that the first block of therapy is regular inhaled corticosteroid treatment.

Imagine this, I have a patient in front of me and can see what problems they have. I clearly need to change therapy, but how do I do that? Refer to the guideline. The big change this time is that people who have got very used to the presentation of stepwise management and, broadly speaking, know what the content of the five main steps are, (trying not to forget the sixth one which is to step down when things are going well) will see something that looks similar but the emphasis is different this time around; the content has altered considerably. Once they get familiar with it the new presentation and content should help improve patients experience and outcomes.

Yes, and that's key in terms of the shorthand which clinicians have used in the past, it's very much that step-process has been central, hasn't it?

It’s really key. So case in point, particularly thinking about NRAD’s key recommendations, some people die from asthma because they rely on a reliever inhaler and aren't taking a preventer adequately. A key change in our pharmacological therapy section is that the first block of therapy is regular inhaled corticosteroid treatment. So, the emphasis is on preventer rather than giving someone a reliever that doesn't actually treat their underlying condition.

So it's about educating the clinician as much as the patient?

I think they are equally important. We need to update our professional colleagues and remind them of the importance of preventative therapy. It’s about letting patients self-manage with a written asthma action plan because we know there is good evidence that these improve outcomes.

Are there two immediate actions you'd recommend that would make a marked difference to improving early and accurate diagnosis of asthma and reducing premature mortality?

I think the diagnostic section is significant and takes quite a different approach from anything that clinicians will have seen before. They will need to read and inwardly digest what it's saying.

It is intended to be clinically useful and practical in primary care. There isn't an over reliance on high-tech expensive tests, it's much more about a “structured clinical assessment”.

It’s about talking to the patient, listening to their story and then taking appropriate measurements. We shouldn’t be put off if things aren't quite as we expect.

One of the issues we have with asthma is that there is no set definition, so it's very hard to pin any sort of diagnostic process against a moving target which is ill-defined. Asthma is variable; there will be times where people are completely normal and times when they’re really gasping and this can change from hour to hour. It's a difficult area to pin down but the new diagnostic chapter takes that into account, offering what we hope is a practical way of approaching that variability.

It is intended to be clinically useful and practical in primary care. There isn't an over reliance on high-tech expensive tests

Does the nature of asthma being a ‘moving target’ mean that clinicians in primary care have perhaps erred on the side of caution?

I think that's a fair comment. I can't immediately put my finger on a lot of evidence and say that's what happens, but people are by nature cautious. They’re trying to reduce avoidable asthma mortality, so if they think someone might have asthma they're probably going to get included in a diagnostic register before long and treated as such, and a number of those patients won't have it.

The diagnostic pathway we advocate is trying to clarify the diagnosis wherever possible, and that means including and excluding people. Sometimes you have to wait and say, ‘Well there's no evidence of it at the moment, but that doesn't mean you haven't had it in the past and similarly that you won’t get it again in the future. We need to keep an open mind.’

And if clinicians do wait to diagnose, arguably the responsibility is placed with the patient to self-manage and input to their own diagnosis? If they go away and then don't come back, but meanwhile ‘live with it’ as people do, what measures exist to bring them back in?

The conversation must be along the lines of, ‘Well it doesn't appear to be an active problem at the moment, but if these symptoms recur you need to come back for re-assessment’. It’s important not to say ‘Well you haven't got asthma, don't bother me again’, so they then stay at home with significant asthma symptoms but without an appropriate management strategy.

So patients wouldn't get called back automatically by way of an asthma register?

You would if you were on an asthma register, which one could argue is a reason for over -diagnosing at that point in time. The only way clinicians can handle that is to say, ‘Well you don't have it as an active problem at the moment’, but if you can put it on some kind of a ‘past problem list’ or an inactive problem list then you can reactivate it.

But that does require the patient to not think ‘Oh, I've been told I'm not asthmatic, so when I get breathless and wheezy at three in the morning it can't be that’. They should be encouraged to say ‘Well it could be that, I need to go back and be retested because now my tests may show evidence of it.’

The diagnostic pathway we advocate is trying to clarify the diagnosis wherever possible, and that means including and excluding people.

There’s no back up in place if you are not on an active asthma register. The asthma register is a process by which you can be called back.

Trying to get to the people you need to see is hard enough. If it is not an active problem they're definitely not going to come.

And presumably the same applies if they are diagnosed, they are put on the register, and then don't show the symptoms again, at some point they can come off?

This may seem a non-sequitur but it highlights an important issue which is perhaps slightly less well recognised or remembered within the pharmacological therapy section. Namely, that when things are going well you step down treatment and, if you do this and problems recur, it's still an active issue.

If you end up withdrawing the therapy altogether and there's no evidence of an active problem, things may well have settled. However that doesn't mean it won't recur at some point in the future. There has to be ongoing flexibility really.

Who should a clinician reading these guidelines refer any queries to?

I think particularly with the significant changes that people are going to see in the new guideline, there will be a lot of questions. We would like to run a number of meetings and presentations to introduce the guideline locally so that people have an opportunity to ask questions and get answers immediately.

In the process of re-writing the guideline there was a period of open consultation. It was presented at the BTS Winter Meeting where people were able to feedback. This was quite an interesting, vigorous debate as you might expect.

It was then sent for peer review, so there have been significant opportunities to comment throughout the guidelines’ evolution.

In terms of clinicians having questions, I would hope local networks and educational meetings will cover this.

How would you say the updated guideline differs from NRAD’s key recommendations in 2015 and what NICE advises on the subject?

NRAD was an important piece of work and I wouldn't say it differs from what we’re saying here, however I believe we've taken note of the important findings and have done our best to improve the guideline. For example, we have considered NRAD findings in making substantial improvements to the pharmacological management section, so that when they end up re-auditing we hope clinicians will be able to demonstrate significant changes for the better.

NICE has previously sent out a draft on diagnosis which was received with some caution. As a result, they are currently undertaking a study to demonstrate that what they recommend is actually practicable in primary care because their diagnostic pathway centres around measuring exhaled nitric oxide levels (FeNO). This is useful because most GPs do not have access to FeNO testing and many I suspect will be unfamiliar with it currently.

Subsequently NICE have embarked on much of the rest of asthma including the pharmacological therapy, but that's in preparation at the moment and won't be available for another 18 months possibly. So at the moment there is no published NICE guideline.

One of the things we're looking to introduce on Respiratory Futures is a national forum for CCG respiratory leads, a networking opportunity for them to share and debate best practice. It strikes me that the guidelines are precisely the sort of topic they’d want to address.

Yes, I think that could be quite interesting.

One obvious challenge is how we “preach to the unconverted”. The people who are interested are the people who are likely to be looking out for it already, come to meetings and will adopt it into their practice and disseminate in their locality.

It's how we engage the people that aren't quite so involved that concerns me. It's a perennial problem, when you hold a meeting the people that turn up are probably not the ones you need to be speaking to.

So where does the guideline go from here?

Other than the need to get it out there, read and implemented, which presents very real challenges, as the guideline is a living document the process will start over.

A review of the process and team membership will be undertaken and then we’ll start to review key questions again according to SIGN methods. We also need to consider all the new developments that will need to be include next time around, which may mean new questions. I’m sure your readers will think of several new topics they’d like to see covered.

It never stops really which is as it should be in such an important and evolving field. Watch this space.

We certainly will, thanks John.

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